The team brings you five ambulatory
surgery center coding and billing tips.
Utilize modifiers that satisfy payer
According to the
director of A/R for NMBS, Mr. Ryan Flesner, particular carriers have various
choices when it comes to modifiers, and coders must know which carriers favor
which modifiers before they hand in a claim. Modifier choices can vary by
carrier and by state, so coders must do their research to prevent turned down
If coders are oblivious of a carriers favored
modifier, he says they can reach the carrier and deliberate how the claim
should be submitted. Once the center sees a denial, the
should be able to pinpoint what brought about the denial and allow the coder
know the carrier?s favored modifier.
Learn the electronic trail of claim
submissions to every payer.
president and CEO of NMBS, suggests that billing managers map out the trail of
electronic claim submissions for each payor. Electronic claims are transmitted
from providers to the providers? EDI Company and, in some situations, on to a
number of trading partners before the claim makes it to the payor. There is
more opportunity for errors, the longer the trail of the claim goes through. To
illustrate, an ASC may utilize an EDI company that does not have a direct
contract with a particular payer. Having this kind of situation, the EDI Company
would transmit the claim to a trading partner, which may or may not have a
direct contact with the payer. If the trading partners do not have a direct
contract, the claim would go to still another trading partner before reaching
the payer. Keeping up on the trail of claims can also give billers a better
knowledge of how long claims will take to reach payers, according to Ms. Rock.
Billing managers can start to outline the trail by
following a claim form the healthcare provider to the provider?s
Company and then find out if the claim goes directly to the payer or to another
clearing house or trading partner. "For each payer, call your EDI provider
and ask if they have a direct contract with that payer. If they do not, ask
where they send the claims next," says Ms. Rock. "After you determine
where it goes next, call there and ask if they have a direct contract with the payer,
and so on."
Remember to verify and authorize insurance.
It is without a question important to make certain the patient absolutely has
coverage before going through a procedure, according to Mr. Flesner. If the patient
lacks the necessary benefits, you will get a denial. While benefits are being
checked, you should always scrutinize the deductible to learn if the patient
has a "trash plan," which means a very low premium and a very high
deductible. Mr. Flesner advises you also not to forget to confirm benefits in
an outpatient surgery center preferably than just outpatient ? there is a
Confirming insurance means trying to reach the
carrier directly for facts regarding the patient?s plan, the forthcoming
procedure, and the essential authorization. In the midst of this conversation,
the carrier can inform you the best way to submit the claim and where to send
it to guarantee it is paid. According to Mr. Flesner, some insurance companies follow
high-volume surgeries to guarantee surgery is important for the condition.
"Carriers are going to look for a history of a more conservative approach
before they offer surgery," Ms. Rock says. "That's why authorization
is so important for some procedures, because maybe carpal tunnel doesn't
require authorization today but tomorrow it will."
Money will be lost if your codes aren't in the correct order.
The moment you have set
down the operative report and you are now familiar which codes to bill, it?s
important to place your codes in the appropriate order, Ms.
Make certain you list your codes from highest to lowest reimbursements so that
you don?t lose money needlessly. For example, Medicare will
lessen the procedure you list second by half, so if you have one procedure
listed at $1,000 and another listed at $750, you want the reduction to be taken
on the $750 procedure so that you lose less money.
It may be doable to adjust your reimbursement if
you commit this error, however Ms. Rock advises making it right the first time
to save yourself a lot of inconvenience.
"It's always possible [to fix it], but if you sequence properly the
first time, you won't have that problem on the back end," she says.
your managed care contract is crucial.
According to Ms. Rock, your biller should have
a copy of every managed care contract and make sense of the details of each
one. "You need to understand how long you have to submit a
claim, how long you have to review an adjudicated claim, what the payment methodology
is, why a carrier would reduce multiple procedures and how to appeal a claim
that hasn't been paid correctly," she says. Your ASC should utilize your
managed care contract to bill out, post payments and make inquiries, and you
need it in each point of the revenue cycle. For example, by carefully reading
your managed care contract, you will refrain from taking an orthopedic case
with a $2500 implant attached when the carrier you use doesn?t reimburse
This concern can be resolved by simple research.
Make certain you have your contacts handy and consult to them often. Knowing
the ins and outs of your contract can assist you in saving money and making you
know the score on which procedures are most lucrative to your center.